Agenda item

To receive a report on the System Winter Plan from Sam Tilley, Director of Planning, Shropshire, Telford & Wrekin Clinical Commissioning Groups and Nigel Lee, Chief Operating Officer, Shrewsbury and Telford Hospital NHS Trust.

Sam Tilley, Director of Planning, Shropshire and Telford and Wrekin Clinical Commissioning Groups, and Nigel Lee, Chief Operating Officer, Shrewsbury and Telford Hospital Trust, were in attendance to present the report before members and answer questions. The report explained that the usual winter planning arrangements were set within a wider Restoration and Recovery Programme for the NHS as a result of the covid19 pandemic. It also explained the requirements set out in the most recent “Phase 3 letter” (12 August 2020) including the acceleration of return to near normal levels of non-covid19 health services and preparation for winter demand pressures alongside vigilance for covid19 spikes locally.

The report explained the differences in planning arrangements for this year and how the benefits to be realised from Covid19 specific learning were being taken on board by the system into the next phase. Planning has been undertaken on the basis of five key themes: Discharge, Hospital Front Door, Community, Primary Care and Acute Services with the overall focus on demand management. Following a rigorous multi-agency process, 30 winter capacity schemes would be utilised in the winter plan across a range of system partners these would start coming on stream from November and there would be close oversight of implementation and impact through the Urgent and Emergency Care Delivery Group and Board and Gold Command. Examples of schemes related to attendance, admission avoidance and discharge to help preserve capacity in the acute trust over the winter months were provided.

The winter plan would be an iterative process and would be monitored and refined as real time data came through. It was also reiterated that the NHS was not closed and as much elective activity as possible was underway and this would be supported through the addition of an additional CT imaging unit and two mobile MRI scanners. Delivery of the vaccination programme would be a huge piece of work from December onwards.

Members asked a number of questions and received responses as follows:

What risk and challenges were there around staff resilience – in a system where this had already been an issue pre-Covid?

It was acknowledged that the challenges already in the system had been exacerbated by Covid 19. There was no easy answer, pressures were immense and staff were tired and stressed already. A System People Group was in place so that partners could manage the next few months and also the longer term. A Memorandum of Understanding had been agreed across key partners in order to redeploy staff to the areas of greatest need.

Support for care homes had been provided in relation to infection control and PPE training was available. As the first wave had arrived later in Shropshire than other parts of the country there had been the opportunity to utilise lessons learnt in relation to discharge into care homes and there was a very strict process of swabbing in place.

There had been an active bring back staff programme and although overseas recruitment had been held up due to Covid travel restrictions, workforce recruits from India were now starting to arrive. Additional staff from private companies were being utilised, eg radiography staff for imaging.

Are more beds needed – how will this be achieved within the limitations of buildings? Is the community bed capacity required available?

Nigel Lee, Chief Operating Officer, SATH said that Future Fit had brought additional capital in order to deliver capacity fit for purpose. The Ambulatory space linked to A&E front door was reducing the need for admissions. The move of the Midwifery Led Unit at PRH alongside the Consultant Led Unit had also provided an increase in capacity but concerns remained. Optimisation of discharge work on a daily basis was a priority and the Trust supported the national agenda of ringing 111 for guidance first. The Director of Planning confirmed that capacity in Community Hospitals was currently good but that ‘home first’ remained the priority with care wrapped around patients as necessary.

What was being done to speed up discharges which were delayed due to waits for medication? Could external pharmacies be used?

This was an issue that SATH had been trying to tackle for a while. Wards were very busy and rounds were led by a consultant, delays stemmed from a wait for discharge summaries and approval for medications. It was intended that wherever possible one or two junior doctors could produce discharge summaries and order medications the day before discharge wherever possible. This remained a challenge as the right level of authority was required to access the medication software. Some improvement had been made but there was still a way to go. A balance between safety and timely discharge was needed. The Chief Operating Officer said he would have to check whether it would be possible to use external pharmacies via using local agreements - there would need to be appropriate stocks and processes in place as there were at the hospital pharmacy.

Discharge – were there delays discharging patients over weekends (an example was cited of a recent case of a delay in discharge)?

Many services were active over weekends although not necessarily on both days or at both sites. Pharmacy, medical staff and additional discharge consultants were on duty every weekend at both sites to facilitate weekend discharge.

At a recent LGA meeting it had been identified that hospitals were very full – not just with Covid patients but with others needing critical care. What was the position locally?

Mr Lee reported that SaTH had not stopped urgent cancer surgery during the pandemic. He confirmed that the hospitals were extremely busy and that critical care covered both covid patients and those with other conditions. The challenge of managing pathways and separating patients with Covid or potentially with Covid was significant.

A critical care surge plan was in place involving use of two operating theatres along with additional equipment. Formal collaboration arrangements were in place with University Hospital North Midlands at Stoke. The Adult Critical Care Network was also active and SATH had recently received some patients from Walsall, as part of providing mutual aid across the network. Active dialogue was maintained across the local, neighbouring and regional system. It would be a continued challenge across the winter.

Is there a dashboard picture showing take up of beds by covid patients/other acute conditions?

This changed on a daily basis – as of now there were covid cases in the mid 20s out of a bed base of about 680. Around a third of critical care capacity was taken up with covid/potential covid cases. Some of the additional capacity planned would not be in place until closer to Christmas. Mr Lee suggested that if the Joint HOSC wanted more information that he discuss specific requirements with the Chair outside of the meeting.

The report referred to ‘what had not worked well with previous winter planning arrangements but must this year’. What more being done to ensure that what not gone well previously would deliver this year?

Whereas lack of flexibility across organisational boundaries and staffing issues had been a feature of the past, covid had helped to move that agenda forward quite significantly. Multi-agency arrangements for sharing staff across the system were now in place and strides forward had been made in working as a system with shared priorities with a default setting of problem solving.

What more was being done to address ambulance handover issues?

Investment and capacity at the front door were essential to addressing this issue, RSH in particular had a small A&E and peaks in demand were harder to manage than they would be in a larger organisation. The investment which would come on line at Christmas involving an ambulatory environment would help provide a better pathway for some patients. Some patients could be supported, treated and discharged the same day with appropriate support at home.

Why are patients coming to A&E if this is not the right place for them?

Work on establishing the right pathways for patients was underway – with a number of these pathways and options being available and evident to primary care, 111 colleagues and also users directly to help avoid admissions.

The Chair thanked Sam Tilley and Nigel Lee for attending the meeting and answering questions. The Committee requested a similar report again in a year’s time with more detail so that members could understand what high level actions would actually look like on the ground. This would help to assure members as lay people. Sam Tilley welcomed this guidance.